Spina Bifida Flashcards
Myelopdysplasia type: Open leison; Spinal nerve paralysis – spinal nerves protruding and sac is not intact; Assumed they do not have bowel and bladder control = spastic bladder –> hydronephrosis
Spina bifida aperta
- Myelomenigocele
Myelopdysplasia type: Hidden leison (non fusion of halves of the vertebral arches); No disturbance of underlying neural tissue
spina bifida occulta
Myelopdysplasia type: Proturding sac containing meninges and CSF (nerve roots and cord are intact); Lipomeningocele - Issues of tethered cord in the future (no problems initially)
Myelocele
How can you screen for spina bifida?
- AFP screen - After 14th week AFP continues to leak into amniotic fluid (positive); AFP peaks at 14 weeks
- Ultrasound - Lemon sign (flat frontal bone from pressure gradient causing brain to descend into spinal canal) prior to 24 weeks gestation
- Aminotic fluid analysis - Chronic villi sampling; Amniocentesis
What are primary impairments of spina bifida?
- Hydrocephalus - Arnold-Chiari Type II: Hypoplasia of cerebellum and herniation through foramen magnum; Deformity of medulla and cervical spinal cord; Caudal displacement of the brainstem; CSF released from the 4th ventricle is disrupted
- Motor paralysis
- Sensory deficits - WB in insensate joints; Skin breakdown
- Cognitive and Language Dysfunction - “cocktail personality”
- Latex allergy
- Upper limb dyscoordination
- Visuoperceptual deficits
- Cranial nerve palsies
- Spasticity and or progressive neuro dysfunction - Tethered cord
- Seizures
- Neurogenic bowel and bladder - All cases!
What are the S and S of shunt problems?
- Change in personality
- Sleepiness
- Lethargy
- Vomiting
- Headache and irritability
What are secondary impairments of spina bifida related to the MS system?
- Club feet
- Flexion contractures
- Dislocated hips
- Scoliosis
- Excessive lordosis
- Rotational deformities of the femur and tibia
- Flexed posture
- Foot deformities (typically pronation)
- 50% of kids with SB are overweight after 6
- osteoporosis
What are PT goals for SB?
- Promote functional skills
- Reduce contractures
- Reduce fractures
- Reduce obesity - Positioning, Age appropriate play, Adaptive devices
- Monitor for CNS deterioration, tethered cord, hydromyelia
What is PT management of SB?
- ROM exercises: parent education, initially in prone and sidelying
- Positioning
- motor development
Pt displays weakness of intrinsic foot m’s; good to normal foot PF (grade 4-5)
Orthotic program? expected ambulation?
- FO
- community ambulation; ability to keep up with peers when walking outdoors
Pt displays fair or less foot PF (grade 3 or less); fair or better knee flexion (grade 3 or more); poor to fair or better hip extension and/or hip abduction (grade 2-3 or more)
Orthotic program? expected ambulation?
- When the child initiates moving in prone position: standing with AFO
- when child initiates steps: walking with SMO or AFO
- in children with tibial torsion or knee rotation risk: walking with KAFO
- community ambulation; walks in the community, w.c use only for long distances outdoors
Pt displays good to normal hip flexion and knee ext (grade +- 5); fair or less knee flexion (grade 3 or less); trace of hip ext, abd, and below-knee m’s
Orthotic program? expected ambulation?
- when child raises to sitting: standing with HKAFO
- when the child initiates steps: walking with HKAFO
- in children with stable hip joints: walking with KAFO
- in children with unstable hip: walking with reciprocating gait orthosis (RGO)
- household ambulation; walks indoors; w/c only outdoors and for long distances indoors
Pt displays no knee ext activity; poor or less hip flexion (grade 2 or less); fair or good pelvic elevation
Orthotic program? expected ambulation?
- when child raises to sitting: standing with HKAFO
- when the child initiates steps: walking with RGO
- Household ambulation; w.c use booth indoors and outdoors
Pt displays no m activity in lower limbs; no pelvic elevation
Orthotic program? expected ambulation?
- when the child initiates reaching with the hand in prone position toward the vertical position: standing with standing orthosis
- when the child initiates ambulation: swivel walker
- nonfunctional ambulation or standing function
What is PT management of motor development in SB?
- Low trunk muscle tone
- Prolonged instability of the head and upper body
- Delayed or weak acquisition of balance and equilibrium responses
- Which activities will likely be most difficult?
- What substitutions may you see?
- Infant Devices?
What are the following sx characteristic of: - Rapidly progressive scoliosis - Hypertonus at one or several sites in the LE’s - Changes in gait pattern - Changes in urologic function - Increased tone on pROM - Asymmetric changes in MMT - Decrease in strength c/o discomfort in the back or buttocks
Tethered cord
What is ambulation prognosis if walking is achieved?
- onset is delayed by about 2 years, compared with infants with typical development
- often involves the use of leg braces
- Walking is usually unstable and energy costly.
Motor level classification?
Some pelvic control is present in sitting or supine (abs or paraspinals); hip hiking from lumborum may also be present
T12
Motor level classification?
Weak iliopsoas m function is present (grade 2)
L1
Motor level classification?
iliopsoas, sartorius, and the hip adductors all grade 3 or better
L2
Motor level classification?
iliopsoas, sartorius, and the hip adductors all grade 3 or better PLUS the quadriceps are grade 3 or better
L3
Motor level classification?
iliopsoas, sartorius, and the hip adductors all grade 3 or better; the quadriceps are grade 3 or better; medial hamstrings or the TA is grade 3 or better; weak per onus terminus may also be seen
L4
Motor level classification?
iliopsoas, sartorius, the hip adductors and quads; medial hamstrings or the TA is grade 3 or better; lateral hamstrings grade 3 or better plus one of the following: glut med grade 2 or better, peronus terminus grade 4 or better, or tib post grade 3 or better
L5
Motor level classification?
exceeds criteria for L5 plus at least 2 of the following: gastroc/ soleus grade 2 or better, glut med grade 3 or better, or glut max grade 2 or better
S1
Motor level classification?
meets or exceeds criteria for S!, the gastroc/ soleus must be grade 3 or better, and glut med and max are grade 4 or better
S2
Motor level classification?
all of the lower limb m grougps are normal strength (may be grade 4 in a couple groups); also includes normal-appearingg infants who are too young to be bowel and bladder trained
S2-3
What is walking prognosis for L1-3, L4-5, and sacral groups?
- L1-L3 = 56% walked but only 32% remained walkers at 10
- L4-L5 = 84% walked but only 73% remained walkers at 9
- Sacral 100% achieve and retain walking
What are implications for fitness?
- Sacral leisons increased risk for obesity - promote physical activity for prevention
- Impaired aerobic capacity - Significantly reduced V O2 peak level - aerobic training beneficial
- Impaired muscle strength - anaerobic and strength training beneficial
- Low peak heart rate - 6 minute walk test reproducible (may need a 20-25% change from baseline)
What are contraindications for physical activity for children with SB?
- recent surgery
- progressive back pain
- poor fitting orthoses
